Test Stations

Surgery / General Surgery: Anxiety


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an F1 junior doctor in General Practice

Patient: Patient has presented to general practice with problems leaving the house

Task:
- Take a history focusing on anxiety symptoms
- After 6 minutes you will be asked a series of questions by the examiner.
- Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 21 year old student, you live with 3 other housemates.

Key details: you are anxious, keep playing with your fingers, have sweaty hands.

  • You used to go to University until a couple of months ago
  • When you used to go you found your heart racing fast, felt dizzy and your hands would be really sweaty. When this happens you have to leave and go home.
  • Over time you have started to feel like this whenever you leave the house. You are able to leave the house with friends but you constantly feel sick and want to go home.
  • You try to avoid going out and have started ordering your food online to avoid going into crowded places such as the supermarket. You avoid leaving the house by telling people you aren’t feeling well or you have lots of uni work to catch up on.
  • You have upcoming exams and you are worried you will not be able to go and as a result will fail the year and be kicked out of uni
  • These symptoms have been getting worse over the past 2 months
  • You struggle to get to sleep and only sleep for about 3-4 hours a night, sometimes you have a sleeping tablet to help this but do not want to become hooked on this
  • You feel down about all of this because you used to be a social person and this is not like the old you at all. Concentration, mood and energy is fine if you are at home. You are still able to be social inside the house

PMH

  • No ongoing medical problems
  • No mental health problems previously

DH

  • Not on any regular medications
  • NKDA

SH

  • You have started smoking recently as this helps. Smoke about 25 cigarettes per day
  • You have started drinking more alcohol as you find after a few drinks the anxiety feeling starts to melt away. About a bottle of wine in the evenings. You have no signs or symptoms of alcohol dependency if asked (not concerned about drinking, no craving, no early morning shakes)

FH

  • Dad sometimes says he has migraines when out in public and has to leave suddenly, you have never asked him about this but you think he has anxiety

ICEF

  • You are not sure what is going on, you are willing to try what the doctor thinks is best

CategoryQuestion
Done
Excellent
IntroductionCandidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


PCCandidate establishes:
When symptoms first began
How this has changed over time
Triggers to symptoms


Psychological anxiety
Worries about judgment of symptoms
Worried about becoming ill if put in situation
Avoidance of stressor
Overestimation of likelihood of negative events
Poor concentration


Physiological anxiety
Increased heart rate
Dizziness
Tingling in hands and feet
Sweating
Dry mouth
Tremor


Elicits when symptoms are worse:
In public spaces
When crowded
Avoidance of situations (ordering food online)
Anticipatory anxiety (won’t leave the house as will be unwell)


Psychiatric history review:
Low mood
Hallucinations (visual / auditory / olfactory)
Paranoid thoughts
Harm to others
Patient ever been elated


PMHPast Medical History
Past psychiatric history
Past history of self harm


DHDrug History
No regular medications
No known drug allergies


SHSocial History
Lives with uni friends
Smokes 25 per day
Drinks 1 bottle of wine a day
Does no illicit drugs


Ability to establish rapport with a distressed patient:
Candidate seems interested in how you feel
Responds to information you provide
Allows appropriate gaps and allows you to give information at your own pace
Conversation flows naturally / are not provided with a load of closed questions


Sensitively asks questions:
Appropriately asks questions
Avoids medical jargon
There are no instances where you find questions bizarre or inappropriately asked


QuestionWhat are your list of differentials?
Agoraphobia with panic attacks
Generalized anxiety disorder
Panic attack disorder
Social anxiety disorder
Obsessive compulsive disorder
Post traumatic stress disorder


QuestionWhat main investigations would you like to do to rule out organic pathology?
TFT – thyroid disease e.g hyperthyroid
Urine drug screen if appropriate
ECG – arrhythmias
Blood pressure – pheochromocytoma


QuestionWhat are the pharmacological treatment options for anxiety?
SSRI: sertraline, citalopram
Beta blocker: propranolol


QuestionWhat are the non-pharmacological treatment options for anxiety?
Cognitive behavioral therapy
Mindfulness
Exercise
Reduction in alcohol
Stopping smoking
Sleep hygiene



Score


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